Surgical Consultation Request

Surgical Consultation Request
We appreciate your interest in consulting with Pennington Facial Plastics for your surgical facial and neck rejuvenation. To facilitate this process, we kindly request that you complete the fields below. Once your submission is received, one of our surgical coordinators will promptly reach out to you to discuss the next steps in your journey. Thank you for considering us for your aesthetic needs.
Name*

First NameLast Name
Sex*
Phone Number*
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best time to contact you*
How did you hear about Dr. Pennington?*
Procedure(s) of interest:

Deep Plane FaceliftNeck LiftFacial Fat TransferDirect Brow LiftLateral Brow LiftEndoscopic Brow LiftUpper Blepharoplasty Eyelid LiftLower Blepharoplasty Eyelid LiftLip LiftChin ImplantBuccal Fat RemovalEarlobe Reduction/RepairRhinoplastySeptoplastyOtoplastyScar RevisionLaser ResurfacingSubmental LiposuctionOther or Unsure
Date of Birth*

MonthDayYear
Height*
Weight*
Are you in the process of losing weight?

YesNo
If so, how many pounds are you from your goal weight?*
Do you use any nicotine products?*
What previous treatments have you had performed on your face/neck/body? Choose all that apply.

Botox / NeuromodulatorsHyaluronic Acid FillersSculptraRadiesseUltherapyThermageFraxelThreadlift ProceduresRF Microneedling (e.g. Morpheus8)Laser Treatment for Facial CapillariesLaser Hair Removal
Have you ever had threads, and if so, when were they placed?*
Have you ever had Ultherapy, Thermage or Morpheus?*
What medical conditions do you have?
Current medications*
Allergic to any medications?*
Budget you had in mind for procedure*
When are you interested in having surgery?*
What cosmetic or functional surgeries have you had in the past? Please list procedure and date of service*
Did you experience any complications from these procedures? If so, please explain below:*
Are you pleased with your previous plastic surgery or aesthetic procedures? If you were not, please explain below:*
We appreciate your valuable input and the time you've dedicated to sharing this information with us. Your commitment to the consultation and surgical process, marked by careful consideration and attention to detail, does not go unnoticed. We extend our sincere gratitude for your active participation, which plays a crucial role in enhancing the quality of our services.

To ensure that we can provide you with the most accurate and detailed assessment during your cosmetic consultation, we kindly request that you complete the following step: please upload digital photographs of your face and neck. The quality of these photos is vital in facilitating our comprehensive evaluation.

For optimal results, we recommend the following guidelines for taking these photographs:
- Choose a well-lit room with ample natural light.
- Utilize a neutral background to ensure clarity.
- Enlist the assistance of a friend or family member to take the pictures.
- Position the camera lens at eye level.
- Ensure that your chin remains parallel to the floor.
- Be certain that both your face and neck are fully within the frame of each picture.
Your cooperation in providing these photographs will greatly assist us in delivering a thorough and accurate consultation. Once again, thank you for your participation in this process. We eagerly anticipate further communication with you.
PDF or JPG Files only (Total File Size must be under 20mb)
Front facing no smile *

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Front facing raising eyebrows*

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Front facing scowling*

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Front facing smile*

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Front facing with just eyes looking up towards ceiling*

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Front facing flexing platysmal bands*

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Right 3/4 view no smile*

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Right 3/4 view smile*

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Right profile no smile *

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Right profile smile *

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Right profile with neck bent looking down*

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Left 3/4 view no smile *

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Left 3/4 view smile *

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Left profile no smile *

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Left profile smile *

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Left profile with neck bent looking down*

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Please be aware that communication conducted through our website or email is not encrypted and may not guarantee security. By completing this form, you are authorizing Pennington Facial Plastics to assess your submitted photos. These images will solely be utilized internally for consultation purposes.
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Surgical Consultation Request

PDF or JPG Files only (Total File Size must be under 20mb)